Chest Pain – differential diagnosis

Chest pain is one of the most common causes of presentation to a cardiologist or emergency room. Often the pain is harmless, without life-threatening and has a non-cardiac cause, but in some cases it can be fatal. It is one of the main causes of overloading emergency departments and at the same time very often not taken seriously by the patients, leading to the failure of early diagnosis of acute myocardial infarction (many patients consider a simple “cold” and go to the doctor only after days). It is often difficult even for a doctor to determine the cause of chest pain immediately.

Any part of the chest can cause pain. Of chest pain, majority are of non-cardiac causes : parietal (pertaining to the chest wall), pleura (pleural effusion), lung (pneumothorax or pneumonia), digestive (reflux esophagitis). Due to the complex distribution of the nervous system in the body, chest pain may originate in other areas of the body (eg abdomen: perforated ulcer, cholecystitis, etc.). Another part have cardiovascular cause and are potentially life threatening. These are the first we think, because they are very serious and require emergency treatment.

The main cause of cardiac pain is ischemia: angina pectoris, acute myocardial infarction. Ischemic heart pain has certain characteristics: it appears and disappears gradually (not suddenly), occurs on exertion, lasts about 10-20 minutes and gives rapidly to sublingual nitroglycerin. It is located in the center of the chest (sternum), sometimes radiating to the left upper limb, the lower jaw or both arms. Usually it is accompanied by other symptoms, but sometimes it can be associated with nausea, vomiting, dyspnea (shortness of breath), dizziness, fatigue (tiredness). This type of pain does not vary with respiratory movements or changing position. None of these characters is pathognomonic (definite diagnosis), but all are indicative only; establishing the exact diagnosis is done by associating this information with those offered by EKG; sometimes are needed further investigation (echocardiography, ECG stress test, CT scan , chest radiography, blood tests etc..). When myocardial ischemia is not very serious, it is possible that between painful episodes EKG may not show changes (but only during pain); if ischemia is more advanced, then changes also appear during painless periods.

Ischemic pain is not the only cause of cardiac pain; other cardiac disorders may be life-threatening and present with chest pain: pericarditis (inflammation of the pericardium – the foil around the heart, with or without accumulation of fluid in the space between it and the heart), aortic dissection (wall rupture of the largest vessel of the body), pulmonary embolism (blood clot in the pulmonary arteries); In such cases there is no typical ischemic pain, but is generally continuous and of variable intensity. The pain intensity is not directly proportional to the severity of the condition.

However, the largest proportion of cases of chest pain is the pain of non-cardiac cause, particularly the parietal and the psychogenic pain. Parietal pain can be traumatic or in most cases inflammatory; it may come from cervico-thoracic spondylosis (a disease of the thoracic spine with anterior irradiation, often accompanied by irradiation on left upper limb), left scapulohumeral periarthritis, Tietze syndrome (inflammation of the joints between the ribs and sternum), herpes zoster; this pain occurs commonly after exposure to cold or after intense physical effort, sudden movements or awkward postures maintained for a longer period (at work, driving, etc..). Generally, this type of pain persists longer (hours-days) and varies with changing body position or breathing movements, it increases at touching and ameliorates after administration of analgesics and anti-inflammatory drugs.

Chest pain is a pain without an organic cause. Is a diagnosis of exclusion. First, it should be excluded other possible causes; occurs especially in patients who have gone through periods of stress, conflict situations, in patients with depression; patients with this type of pain very often go to doctors, do a lot of investigation, receive multiple treatments without being convinced that they don’t have a heart condition; often refuse psychological or psychiatric assistance. Sometimes it can occur in the context of panic attacks accompanied by fear, breathlessness, sweating, palpitations.

Given the many possible causes of chest pain and the risk of dying of certain diseases, it is recommended for the patient to seek a specialist advice as soon after the onset of chest pain, even if it is subsequently established that the condition is not serious. Therefore, it is useful that family physicians to have an electrocardiograph at cabinet to quickly diagnose an acute coronary syndrome and lead to emergency departments. Patients with known heart disease or hypertension who develop an episode of chest pain should go directly to a cardiologist.